ReflexologyIntake Form How did you hear about me? Your First and Last Name: Age: Your email: Your Address: City: ZIP Code: State: Phone/Cell: How would you rate your state of health? ExcellentGoodFairPoor Are you currently under a doctor's care for a specific issue? State Yes or No. If so, explain. Women - are you pregnant? State Yes or No. And if so, how long? Are you taking any medications? State Yes or No. Please List. Have you had any surgeries? If Yes, please explain. Are you experiencing any pain or problems with your feet? State Yes or No. If Yes, please describe. Where do you hold your tension in the body? (neck, shoulders, back, stomach, other) How would you rate your level of stress? 1-10? Why are you trying Reflexology? Occupation? Retired? How Long? I understand that it is not within the scope of a Reflexologist to diagnose illness, disease or any physical or mental disorder, prescribe medical treatment or pharmaceuticals. Reflexology is not a substitute for medical treatment but a complement to most therapies. Reflexology believes that the entire body is mirrored on the feet, hands and ears. By working these areas with certain thumb and finger techniques, the energy pathways in the body can unblock allowing circulation and movement, which in turn will aid the body in restoration. Reflexology promotes balance and delivery of oxygen and nutrients to the cells. By signing this form I give consent to a reflexology session. I take responsibility if I discontinue any prescribed treatment by a licensed health professional. I have stated all my known medical conditions and take it upon myself to update my health status during subsequent visits. This form uses Akismet to reduce spam. Learn how your data is processed. Δ
